Catatonia in Outpatients: Analysis of a Single Clinical Practice. Robert Arnold
Johnson, MD
SUPPLEMENTAL DIGITAL CONTENT
Means of diagnosis in this study. Diagnoses for each patient in this outpatient practice
of general psychiatry during a period extending from the inception of the practice
(September 2007) to December 2013 were reviewed by means of a record-by-record
survey. These surveys were retrospective: neither diagnosis nor treatment was conceived
according to an interventional or experimental design. The patients in the practice are
subject to the psychiatric evaluation and care of a single provider, the author, who alone
creates the record of clinical encounters. All diagnoses are based on informally structured
clinical interviews, but extended, in all of the cases reported herein, to multiple
encounters over months or, more commonly, years.
Diagnoses conform to criteria specified in DSM-5; one instance of catatonia is an
exception (see Table). For purposes of this study, the Bush-Francis Catatonia Rating
Scale (BFCRS) is employed as a supplemental tool for diagnosing catatonia (6). Answers
for each of its 23 items are not specifically sought in these clinical encounters, so the
score entered in each case accounts for items answered within the record, and assigns a
score of 0 to the others: the score here is a minimum value, therefore. In the case of ASD
in adult patients not previously diagnosed, the clinical interview in itself may leave
doubt, especially with regard to the certain presence or absence of typical childhood
symptoms and signs (Criterion C, DSM-5); the modifier “likely” is assigned to the
diagnosis in such instances.
The Practice and Its Community
This outpatient practice of general adult psychiatry is located in Walla Walla, the
largest city in a semi-rural region of approximately 55,000 in southwestern Washington
State. Walla Walla is known for wine-making (more than 100 wineries), (sweet) onionfarming, dry-land wheat farming, higher education (two colleges and one community
college), and Washington State Penitentiary, Its population is 22% Hispanic, 2.7%
African-American, 1.4% Native American, and 1.3% Asian. This information about the
community in which the practice is embedded is taken largely from the 2010 census. The
author is the only psychiatrist in general practice in the immediate region. Two general
hospitals are located in the city; there is no inpatient psychiatric unit. The closest provider
for electroconvulsive therapy (ECT) is removed by 130 miles.
No one living independently is taken into the practice who is deemed incapable of
keeping scheduled appointments and being free of intoxication while in-session,
incapable of maintaining basic hygiene, and incapable of restraining an impulse to
physically assault. No new patient actively psychotic is accepted unless a supportive
family member or staff-member of a care-facility is available and willing to accompany
him or her to the session. If a patient lacks capability—physically, mentally, or
financially—for coming to a session and resides in a sufficiently safe and supportive
home or facility, the author is able to attend him or her there, given enough notice for
scheduling. Eighty percent of the patients are insured, either privately (70%) or via
Medicare (10%). Of those who pay themselves, 79% are extended a means-based
reduction in fee; a very few are wholly unable to pay. The practice does not bill Medicaid
in Washington or in the nearby state of Oregon. The practice does not include children;
only four of the patients have been less than 18 years of age. Of patient-contact hours, a
majority (75%) involve psychotherapy, at least in part—solely psychotherapy in 25% of
these; in the remainder, clinical attention is confined principally to medication
management and evaluation.
Case Report1
A 55-year-old man, the youngest of 5 siblings, was brought for ongoing psychiatric
care. His mother, age 95, stated that all developmental milestones were late, thus he was
considered intellectually impaired early in childhood, even though savant skills
(calendric; memory for strings of numbers) were recognized also. Reciprocal social
interaction was always impaired; self-presentation was immature and ritualistic. Bullying
by peers began in 1st grade. He was placed in special education by 7th grade; school ended
in 10th grade. A recurrently disruptive feature of childhood, persisting since, was that of
assaultive explosion: battery occasioned three inpatient psychiatric hospitalizations
through the years and a rare overnight confinement to the local jail. He lived at home
until age 27, then in a series of residential facilities, from which he traveled by foot or
local bus to day-treatment or a work-center. Never was he capable of independent living.
Never did he fall in love. His mother in her later years believed that autism was the best
diagnosis for her son; I was the first mental-health provider to agree. The most common
diagnosis in his records was schizoaffective disorder, despite absence of hallucinations or
delusions (confirmed by a nurse who had seen him for years) and absence of the
disordered moods typical of that diagnosis. The assaultive explosions were very brief;
they did not mark an epoch of disturbed mood. The social and communicative
1
The patient described here, despite the author’s masking or withholding the most obviously identifying
features, is yet recognizable by a few within the small city in which the practice is located. Informed
consent for publication of the case has been provided by his two living siblings. (Although the patient
himself also has provided consent, he lacks capacity for doing so, in the author’s opinion.)
impairments of autism seem to have been confused with the negative features of a
schizophrenic illness. Echolalic repetition had been common. Sometimes answering a
doorbell he would be overtaken by inexplicable mutism. Lorazepam had been prescribed
and continued, but nowhere in the record was a diagnosis of catatonia stated explicitly. I,
too, failed to consider it at first.
He is a very large man, and on presentation was clean, casually attired, cooperative, and
pleasant. Eye-contact was inconsistently engaged, and he spoke with an odd, fixed
prosody. One instance of echolalia was noted. Affect was euthymic but restricted in
range. Neither hallucinatory nor delusional experience was in evidence. Orientation was
normal, with the exception that he had trouble naming the country without a prompt. He
could spell “world” rapidly, forward and back. Judgment was fair, insight poor. He knew
no proverbs; he recognized biblical passages, but could offer no interpretations. No
hyperactivity, immobility, posturing, staring, mutism, ambitendency, or oppositional
behaviors were present then. The score on the Folstein mini-mental-status exam was 21
of 30. IQ, estimated by the verbally based Ammons Quick Test, was 78. Medications had
not changed in over a decade: thioridazine, haloperidol, procyclidine, diphenhydramine,
sertraline, lorazepam (2 mg three times daily), and fludrocortisone. ECG showed QTc of
0.47 s. Complete blood count and the results of a metabolic screen were normal. The
rationale for the prescription of two antipsychotic agents appears to have been a trial-anderror conclusion that both were needed to prevent enactment of the impulse to assault.
Thioridazine was tapered and discontinued as aripiprazole was added. He became more
cheerful and conversational; his mother was so impressed that she hired a tutor.
Clonazepam was substituted for lorazepam, with a plan for slowly tapering off
benzodiazepine altogether; procyclidine and diphenhydramine were discontinued. Three
months later, when the dose of clonazepam was half the initial amount, his caretaker
complained that the patient seemed confused and uncoordinated. Spontaneous speech
was diminished but he answered questions reasonably. Performances on the Folstein test
and clock-drawing were unchanged. Confabulation, however, was newly present.
Neurological examination showed nothing remarkable otherwise. CT-scan of the head
was normal, as were the results of repeated laboratory testing, including TSH and vitamin
B12 serum levels. Over the next 18 weeks clonazepam and aripiprazole were tapered off,
the latter on the speculation that this unexplained change in functioning might represent a
delayed cognitive effect of the drug. No sustained improvement occurred. In fact,
spontaneous speech declined further. He began episodically to urinate into his trousers,
sometimes standing in view of others as if on show, and similar behavior was true of
defecation; sometimes he would play with his feces (copromania) before the watchful
gaze of others. Yet he remained fully oriented and alert, with no hallucinations or
delusions. At that time he began holding the left upper extremity in an odd, anglepoise
posture: I made the diagnosis of catatonia. Lorazepam three times daily was prescribed,
and the dose gradually advanced. Distinct improvement occurred quickly and was
pronounced within a month. Occasional spells over the next 3 years of the following have
provoked further adjustment in the dose of lorazepam and the re-introduction of
aripiprazole: public masturbation; assaultive explosions (verbal or physical); bedwetting;
abrupt, bizarre food-stuffing (to the point of near-asphyxiation, requiring a visit to an
emergency room); one instance of sitting down on a highway; echopraxia; echolalia;
staring; an exaggerated manneristic smile; a temporary but dramatic “shuffle” in gait; and
pronounced mutism. Once, when asked why he had suddenly blurted out, “I wish I was
dead or could kill somebody!” he answered, “I’m not going to talk like that anymore; yet
I don’t know that I can stop; maybe I do it for attention.” In the past year he is free of all
such catatonic features, apart from rare posturing of the left upper extremity. He exercises
at the YMCA twice weekly, attends church each Sunday, and goes out to lunch with one
of his caretakers weekly. Medications are lorazepam three times daily (total of 10 mg),
aripiprazole 30 mg daily, sertraline 100 mg daily, and haloperidol 10 mg at bedtime.